Implementing a Five-Level Emergency Severity Index (ESI) Triage

Innovation:The Emergency Severity Index (ESI) is a five level patient acuity classification that is assigned at the time of triage. Hahnemann successfully implemented it to replace the existing four level program.

Result: The five level ESI system provides a much more accurate description of the emergency departments (ED’s) patient mix. The rates of patients classified as level four’s or five’s have increased at Hahnemann which is likely a result of ESI based triaging, giving the ED a better idea of the “real ED population” they are serving.

From the experts: “We have had a very smooth transition and process change, and I think you can attribute that to how well this transition was planned and supported. I’ve worked at places that have intended to implement five-level triage, but because of inadequate planning and organizational support, it flops.”

Located in the heart of Philadelphia, Hahnemann University Hospital is a 540-bed tertiary care institution with a large percentage of beds dedicated to intensive care.

Clinical areas affected:

Emergency department

Staff involved:

Nurses

Physicians

Administrators

Timeline:The entire process from the conception of the plan to the beginning of the implementation lasted about six months, including an initial implementation and training as well as a retraining and refresher course for staff.

Innovation implementation:Five-level triage is becoming standard at many hospital emergency departments (EDs), particularly those in Philadelphia. Wanting to close the gap with other hospitals and improve their operations, the team at Hahnemann University Hospital decided to implement a plan where they could transition the current triage process from four to five levels.

They found that education is absolutely critical to this plan—it helps change the culture dramatically and improves the likelihood of a successful implementation. They had an initial education process for staff, and then several months later, a retraining and refresher course. Coincidentally, around the time they were implementing this plan, the hospital was also converting its records from paper to electronic, which helped support this project immensely.

The result of the switch is that Hahnemann’s staff has begun to understand that the “real ED population” is comprised of approximately 8 percent more ESI Level IVs and Vs than previously thought, which should lead to improved patient flow as resources can be better planned for and allocated.

Advice and lessons learned:

A good top-level manager needs to ensure the process keeps going. But don’t micromanage. For this project to succeed, people need to peer audit each other, and not feel like their manager is breathing down their necks. But the project does need firm guidance on the basic direction.

Having data is essential. Continue collecting data even when it is not the data you want to see. You need to understand how the transition is going, and what you can do to affect it.

Don’t be afraid of challenging institutional norms. This project is all about shaking things up. So don’t be afraid of ruffling feathers, as long as you’re sure it’s for the best.